Association of Secondary Preventive Cardiovascular Treatment After Myocardial Infarction With Mortality Among Patients With Schizophrenia

Abstract

IMPORTANCE Cardioprotective medication use is an important secondary preventive treatment after cardiovascular events. Patients with schizophrenia have excess cardiovascular morbidity and mortality, but no studies have investigated whether taking recommended cardioprotective medication can reduce this excess mortality. OBJECTIVE To assess the association of exposure to secondary cardiovascular treatment with all-cause mortality after myocardial infarction among patients with schizophrenia compared with the general population. DESIGN, SETTING, AND PARTICIPANTS This nationwide cohort study included individuals admitted with first-time myocardial infarction in Denmark from January 1, 1995, to December 31, 2015. The cohort was dichotomously divided by a diagnosis of schizophrenia. Data on the prescription of guideline-recommended cardioprotective medication, including antithrombotics, β-blockers, vitamin K antagonist, angiotensin-converting enzyme inhibitors, and statins, were obtained from the nationwide registries. EXPOSURES Time exposed to cardioprotective medication. MAIN OUTCOMES AND MEASURE Cox proportional hazards regression was used to calculate hazard ratios (HRs) with 95% CIs for the association between treatment exposure and all-cause mortality after myocardial infarction between patients with and without schizophrenia. RESULTS The cohort included 105 018 patients with myocardial infarction, including 684 patients with schizophrenia (0.7%; 483 male [70.6%]; mean [SD] age at diagnosis, 57.3 [10.6] years) and 104 334 general population patients (99.3%; 73 454 male [70.4%]; mean [SD] age at diagnosis, 61.0 [10.6] years), with a total follow-up of 796 435 person-years and 28 059 deaths. Patients diagnosed with schizophrenia who did not receive cardioprotective treatment had the highest mortality rate (HR, 8.78; 95% CI, 4.37-17.64) compared with the general population treated, with treated patients diagnosed with schizophrenia having an increased HR of 1.97 (95% CI, 1.25-3.10). The analyses of the associations of different cardiac therapy strategies with mortality rates revealed that patients with schizophrenia who were treated with any combination of triple therapy had mortality rates similar to those observed in the general population (HR, 1.05; 95% CI, 0.43-2.52) in the multivariable analysis. CONCLUSIONS AND RELEVANCE Cardioprotective medication after myocardial infarction should be carefully managed to improve prognosis. The study results suggest that some of the increased cardiac mortality among patients with schizophrenia can be reduced if these patients are efficiently administered combinations of secondary preventive treatments after cardiac events.

The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness

“…For example, cardiac mortality in severe mental illness is significantly reduced by efficient administration of cardioprotective medications after first cardiac events. 356 This confirms assertions in new guidelines (See table 5) and Part 3 that dissemination of tertiary prevention measures in people with mental illness is often overlooked, despite their potential to improve health and reduce premature mortality.…”

“…126 However, contra-indications to specialized interventions, such as smoking or problems with informed consent, are less relevant to the prescription of vascular drugs such as ACE inhibitors, beta-blockers, or statins known to reduce subsequent morbidity and mortality. 127 Furthermore, recent data have shown that people with schizophrenia are equally adherent to diabetes medication as the general population, thus further supporting the need for healthcare providers to remain optimistic about prescribing cardiometabolic medications in people with mental illness. 128 Finally, access may be compromised by financial costs, fragmentation of care and stigma.…”

Increased mortality from somatic multimorbidity in patients with schizophrenia: a Danish nationwide cohort study

“…Several studies have reported that patients with SMI receive less medical prophylaxis as well as fewer invasive procedures during hospitalization as compared to people without SMI . However, a recent observational study showed that exposure to secondary preventive cardiovascular treatment was associated with a reduced excess mortality in patients with schizophrenia . This association is not necessarily causal due to the risk of residual confounders, although it suggests that some interventions might work to reduce some of the excess mortality in patients with schizophrenia.…”

Time Trends in the Use of Coronary Procedures, Guideline-Based Therapy, and All-Cause Mortality following the Acute Coronary Syndrome in Patients with Schizophrenia

“…A Danish study [18] investigating the association between exposure to cardioprotective treatment after myocardial infarction and mortality rates, found that treatment decreased the mortality hazard rate (HR) ratio in patients diagnosed with schizophrenia from 8.87 to 1.97, and in the general population, lack of treatment increased the HR to 2.95 from 1 (reference value). At baseline, we found patients with schizophrenia to have almost double the prevalence of diabetes, COPD, and stroke, which corresponds to the values found in previous research [2,[18][19][20][21]. Over time, risk factors for ischemic heart disease, including diabetes mellitus, hypertension, and COPD, were also increasingly prevalent.…”